Medicines Safety in Care Homes

Medicine Safety in Care Homes

The aim of the programme is to reduce medicine administration errors in care homes by 50% by March 2024, through medicines optimisation and quality improvement.

The HIN engaged with care home professionals including care home managers, pharmacists, GPs, nurses and carers through the Promising Practices event which was designed to explore the implications of medicines administration and provide a platform to learn with and from one another.

Based on the prioritised issues, the HIN worked extensively with eight care homes (Adult Nursing and Learning Disability), focusing on two change interventions namely: Safety huddles and Learning from errors. (premortem session).

Daily Safety Huddles

The aim of the huddles is to foster safety culture through a daily medicines’ safety huddle in the care home. The huddle aims at integrating medicine safety into the daily routine of the care home so that there is increased awareness of medicine safety issues which could positively impact the quality of care for residents.

The huddle is carried out by creating a space to meet for approximately 5-15 minutes discussing new residents, discharges from hospital, medication changes, soft signs of deterioration, NEWS2 scores concerns and end of life care planning. The test huddles were designed to be led by staff over a period of 14 days using the toolkit provided.

Pre-mortem – Learning from Safety Huddles

The pre-mortem is a type of learning Safety Huddle that focusses on learning by reflecting on examples of incidents or near misses that have occurred at another care home and imagining the same scenario happening in their care home. The tool provides the opportunity to create a space where staff re-imagine the future and learn from failure before it happens.

The uniqueness of the pre-mortem tool is that it is non-punitive and void of any blame. The care home staff must imagine that a resident safety incident that occurred elsewhere has instead occurred in their care home, despite all the team’s efforts, and their commitment to deliver safe care for their residents. Things have gone completely wrong on several fronts. The pre-mortem session is an analysis of all the reasons the error occurred thereby giving an opportunity for everyone to work together to develop plans to mitigate these reasons for failure.  The pre-mortem session is run as a four-step structured but interactive workshop guided by an adapted toolkit.

We're here to help

If you have any questions or would like more information about medicines safety in care homes, please contact Alison White, Head of Patient Safety.

Get in touch